Presacral tumors and cysts in adults

Management of presacral tumors: Our experience with posterior approach

INTRODUCTION

Presacral tumors are a rare variety of space occupying lesions arising in the presacral space. Most of the tumors are congenital in origin. Due to obscure anatomic location, difficult surgical approach and etiological heterogeneity, tumors arising here pose a diagnostic and therapeutic challenge. We report our experience of 10 cases of presacral tumors with posterior approach being used in 6.

MATERIALS AND METHODS

A retrospective analysis was conducted on 10 cases of presacral tumors managed at our hospital during a period of 14 months (May 2013-July 2014). 9 cases were operated while one had advanced disease and was referred for palliative care. Complete en bloc excision of the mass was possible in 8 cases. Finally, presenting complaints, clinical diagnosis, surgical procedure and histopahological findings of the cases were studied.

RESULTS

All of our patients were females in the age group of 18-50 (mean 28.4) years. The pathological findings included schwannoma, leiomyosarcoma, hemangiopericytoma, neurofibroma, paraganglioma and rest were developmental cysts. 6 cases were managed using the posterior approach and rest by anterior approach. There was no major complication or mortality in the follow up.

CONCLUSION

Complete surgical excision remains the mainstay of therapy. Surgical approach depends upon the location, size, local invasion and surgical expertise of the surgeon. Benign tumors have a good prognosis while the prognosis in malignant tumors remains guarded due to difficulty in obtaining safe resection margins. Posterior approach is an attractive option for low lying, benign tumors that is more direct, with better exposure and quicker recovery.

Surgical treatment of retrorectal (presacral) tumors

Retrorectal (also known as presacral) tumor (RT) is a rare disease of retrorectal space. They can be classified as congenital, inflammatory, neurogenic, osseous, or miscellaneous. The most common presentation is an asymptomatic mass discovered on routine rectal examination, but certain nonspecific symptoms can be elicited by careful history and physical examination. The primary and only satisfactory treatment is surgery for RTs. Three approaches commonly used for resection are abdominal, transsacral, or a combined abdominosacral approach. Prognosis is directly related primary local control, which is often difficult to achieve for malignant lesions.

Retrorectal/Presacral epidermoid cyst: report of a case

Although epidermal cysts are frequently observed throughout the body, they are rarely found in the retrorectal/presacral regions. Retrorectal epidermal cysts are congenital lesions of ectodermal origin and generally occur in women during the reproductive period. In this case report, a 47 year old female patient with 25 years of complaint of a mass extending from the perianal region to the retro-coccygeal region is discussed. A total mass excision with paracoccygeal incision was performed under spinal anesthesia. The histopathologic examination demonstrated an epidermal cyst. Correct diagnosis and appropriate treatment when first detected significantly decrease the recurrence and complication risks in all retrorectal tumors. Any mass should be completely removed in the treatment.

Robotic excision of a pre-coccygeal nerve root tumor

Pre-coccygeal ganglioneuroma is a rare clinical entity that presents incidentally or with non-specific symptoms. We present a case of a 25 year old housewife who was incidentally diagnosed with pre-coccygeal ganglioneuroma while getting investigated for primary infertility. The patient had no specific complaints except for irregular menstruation which had started 8 months back. Magnetic resonance imaging (MRI) was suggestive of a presacral and pre-coccygeal lesion. Resection of the tumor was done through the anterior approach using the da Vinci Si robotic system. Two robotic arms and one assistant port were used to completely excise the tumor. Robotic excision of such a tumor mass located at a relatively inaccessible area allows enhanced precision and 3-dimentional (3D) view avoiding damage to important surrounding structures.

Laparoscopic excision of retrorectal tumours

AIM

The aim of this study was to demonstrate a laparoscopic technique for the excision of retrorectal tumours.

METHOD

A retrospective review of cases identified from a prospectively maintained database was undertaken.

RESULTS

Ten patients (seven female; median age 45 years (range 23-79) underwent successful laparoscopic excision with no significant morbidity or intra-operative mishaps.

CONCLUSION

The procedure was deemed to be safe and we include a video to show the operative technique.

Pandora's box and retrorectal tumors in laparoscopy: A case report and review of the literature

INTRODUCTION

Retrorectal tumors are uncommon and the etiology diverse. Literature to define the preoperative diagnosis and plan the intraoperative management are uncommon.

PRESENTATION OF CASE

We describe a case of a 44 year old patient with a laparoscopic approach for the removal of a retrorectal tumor and emphasize on the preoperative diagnostics and the intraoperative, minimal invasive approach.

DISCUSSION

Especially because these tumors are rare and often an incidental finding in gynecologic surgery, it is important to know the various differential diagnoses and its consequences with the laparoscopic approach.

CONCLUSION

We suggest the laparoscopic approach in cases of retroperitoneal cysts of unknown origin is ideal also because anatomic structures, mostly nerves, can be easily spared.

Surgical outcomes in adults with benign and malignant sacrococcygeal teratoma: a single-institution experience of 26 cases

BACKGROUND

Adult sacrococcygeal teratomas are rare, and limited data exist on their management and outcomes following surgery.

OBJECTIVE

The aim of this study was to review the outcomes in adult patients undergoing surgery for sacrococcygeal teratomas.

DESIGN

A retrospective review of our prospectively maintained surgical pathology and tumor registries was conducted.

SETTING

This study was conducted at the Mayo Clinic in Rochester. Information was collected on patients treated between 1980 and 2013.

PATIENTS

A total of 26 patients with sacrococcygeal teratoma were identified (19 female), with a median age of 37.5 years. Malignancy was seen in 5 patients.

MAIN OUTCOME MEASURES

Data on demographics, clinical presentation, tumor pathology, adjuvant therapy, surgical approach, surgical margins, use of preoperative biopsy, radiological investigations, morbidity, mortality, and local recurrence was collected. Complications were assessed by using the Clavien-Dindo system of classification.

RESULTS

Patients most commonly presented with pelvic pain (n = 16) and/or a palpable mass (n = 15). On radiology, 8 lesions were purely cystic, 14 were mixed, and 4 were solid; teratoma was suspected as a diagnosis in 8 patients. Preoperative biopsy (13 patients) had 100% concordance with final pathology. Median tumor size was 6 cm, and the surgical approach was posterior only (n = 15), anterior only (n = 5), and combined anterior-posterior (n = 6). Of 5 patients with malignancy, 3 died of recurrent disease.

LIMITATIONS

Limitations of this study include the small number of patients, the long study period, and the heterogeneous nature of these tumors.

CONCLUSION

Presacral teratomas require multidisciplinary management and have a risk of malignant transformation. They are more common in females, and the majority are intrapelvic in location in adults. We recommend clinical evaluation, radiological investigation, and image-guided biopsy in all suspicious presacral lesions. A treatment algorithm has been designed to improve the management of these rare tumors.

A laparoscopic approach to benign retrorectal tumors

BACKGROUND

Retrorectal tumors (RTs) are rare in adults. Their surgical excision is often difficult because of their anatomic location. The aim of this study was to evaluate the results of straight laparoscopic resection of RTs in our institution.

METHODS

Eight patients (six women and two men) with benign RTs were treated by laparoscopic resection in our tertiary care center between September 2012 and June 2013. Exclusion criteria included malignant tumors, lesions with fistula formation, and anterior sacral meningoceles. Clinical data, imaging features, operative details, pathological results, and treatment outcomes were reviewed and analyzed.

RESULTS

Eight cases of benign RT with an average diameter of 8.9 ± 1.7 cm were treated by a straight laparoscopic procedure. The mean operative time was 122 ± 36 min, and the average intraoperative blood loss was 46 ± 33 ml. The median postoperative stay was 5 days (range 3-8 days), and all patients were discharged without serious complications. During a median follow-up of 11 months, no tumor recurrence was observed.

CONCLUSIONS

In our experience, a laparoscopic approach is safe for removing benign tumors in the retrorectal space. This approach may provide access to this difficult-to-reach space and has the advantages of allowing excellent visualization, meticulous dissection, less morbidities, and fast recuperation.

Preoperative assessment of retrorectal tumours

Background

Retrorectal tumours present diagnostic and surgical challenges. This study aimed to identify whether preoperative imaging and/or biopsy provide diagnostic accuracy.

Methods

A consecutive series of patients who had undergone excision of a retrorectal tumour were identified from a database (2002–2013). Details of patient demographics, preoperative presentation, imaging, biopsy, surgical procedure, and gross and microscopic pathology were reviewed. Preoperative imaging and/or biopsies were compared with eventual pathology findings.

Results

In total, 76 patients were identified, all of whom had undergone preoperative cross-sectional imaging whereas only 22 had preoperative biopsy. Imaging correctly discriminated benign from malignant tumours in 72 of the 76 patients (specificity 97 per cent, sensitivity 88 per cent, positive predictive value 88 per cent and negative predictive value 97 per cent). The corresponding values for preoperative biopsy (benign versus malignant) were 100, 83, 100 and 93 per cent. None of the four patients who were assessed incorrectly as having benign or malignant disease on imaging would have undergone an alternative procedure had this been known before surgery. Preoperative biopsy did not significantly influence patient management, and the absence of preoperative biopsy had no detrimental effect; a definitive preoperative histological diagnosis would not have influenced subsequent management.

Conclusion

Preoperative imaging was accurate in the assessment of retrorectal tumours, whereas biopsy did not add to the surgical strategy.

Retrorectal epidermoid presenting as difficulty in bowel evacuation

A rare case of retrorectal epidermoid is presented which was diagnosed by digital rectal examination and sonography. The tumor was removed through perinial approach. Literature of this rare tumor is briefly described.

Lesions originating within the retrorectal space: a diverse group requiring individualized evaluation and surgery

BACKGROUND

Tumors occurring within the retrorectal space are rare and their low incidence has led to a paucity of literature regarding them.

METHODS

Adult patients with retrorectal tumors managed at this institution from 1981-2011 were identified. A retrospective chart review was conducted to obtain relevant data.

RESULTS

Retrorectal tumors were identified in 87 patients (67 female) with median age at diagnosis of 44 years (19-88), and median follow-up 8 months (0.1-225). Of the 25 different histologic tumors diagnosed, hamartomas were most common (32 %; n = 28) followed by epidermal cysts (11 %; n = 10), and teratomas (10 %; n = 9). Twenty-six percent (23/87) of all tumors were malignant. CT scans were obtained in 84 % (73/87) of patients, MRI in 59 % (51/87), and TRUS in 16 % (14/87). While 74 % (64/87) of tumors were at or below the S4 level, operative approach was strictly posterior in 73 % (46/63) of these tumors. Twenty-eight percent (24/87) of patients underwent diagnostic biopsy with no reported biopsy site recurrence. Thirty percent (7/23) of resected malignant (all recurrences: distant) and eleven percent (7/64) of benign tumors (all recurrences: local) recurred. Survival was 70 % (16/23) for malignant tumors and 98 % (63/64) for benign tumors.

CONCLUSIONS

Retrorectal tumors remain heterogeneous and a diagnostic challenge. Pre-operative imaging may help guide surgeons; however, malignancy portends worse outcomes. Despite preoperative biopsy site recurrence concerns, no patient in this study had biopsy site recurrence. As their natural history remains unclear, more studies are necessary to further characterize their behavior.

Neurological outcome following resection of benign presacral neurogenic tumors using a nerve-sparing technique

BACKGROUND

Benign presacral nerve sheath tumors represent up to 10% of all presacral tumors. Limited data exist regarding the impact of the surgical technique on neurological outcomes following resection.

OBJECTIVE

The aim of this study was to test our hypothesis that a nerve-sparing resection technique results in the improvement of preoperative neurological dysfunction and minimal postoperative neurological morbidity.

DESIGN

This study is a case series of all patients with benign neurogenic presacral tumors operated on by the same 2 surgeons between 2004 and 2010 at our institution.

SETTINGS

This study was performed at a tertiary care center.

PATIENTS

Adult patients with benign presacral neurogenic tumors who underwent a nerve-sparing resection were included.

MAIN OUTCOME MEASURES

Postoperative urogenital, anorectal, and lower-extremity neurological functions were analyzed.

RESULTS

Seventeen patients were identified with a mean age of 40 years; 14 were women. Preoperatively, 13 patients had symptoms from neurological dysfunction or presumed mass effect of the tumor. The mean tumor size was 7.4 cm. The pathology was a schwannoma in 12 patients and neurofibroma in 5 patients. Mortality was nil, and 30-day morbidity was noted in 3 patients (hemorrhage, ileus, acute respiratory distress syndrome, deep vein thrombosis, and transient foot drop). Mean follow-up was 36 months. Of the 13 symptomatic patients, 7 achieved complete resolution of symptoms and 5 had improved, but persistent symptoms. None of the 4 asymptomatic patients developed postoperative neurological dysfunction.

LIMITATIONS

Small sample size was a limitation of this study.

CONCLUSIONS

With the use of a nerve-sparing technique, function-preserving resection can be safely completed with an overall improvement in symptoms.

Laparoscopic approach for retrorectal tumors

BACKGROUND

Retrorectal tumors are uncommon and may represent a surgical challenge. Laparoscopic excision has been reported in very few papers. We present our experience of nine cases operated by a transabdominal laparoscopic approach, between 2005 and 2011.

METHODS

There were two males and seven females with a mean age of 35 years (range 19-48). The tumors were discovered incidentally in four cases or because of nonspecific clinical signs. All patients have had an MRI preoperatively.

RESULTS

Only one patient required open conversion due to a huge tumor >7 cm of diameter. Postoperative mortality was nil. One patient developed a hematoma in the pelvic area. The median hospital stay was 4.7 days (range 4-8). Final diagnostic were as follows: four schwannomas, one ganglioneuroma, two tailgut cysts, one anterior meningocele, and one paragangliomas. During the follow-up showed no recurrences, but four of nine patients developed neurologic complications as parenthesis and sciatic pain and one patient developed retrograde ejaculation.

CONCLUSIONS

Our case series shows that the laparoscopic approach is a feasible and safe option. It reduces surgical trauma and offers an excellent tool for perfect visualization of the deep structures in the presacral space to minimize the vascular and neurological injuries.

Retrorectal tumours: optimization of surgical approach and outcome

AIM

The aim was to identify the radiological features of retrorectal tumours that influence management and to highlight technical points that facilitate safe surgical excision.

METHOD

A consecutive series of patients was identified from a prospective database. All cases were discussed within a multidisciplinary team. Medical records, radiology and pathology reports were also checked retrospectively.

RESULTS

Fifty-six patients [37 women; median age 51 (20-88) years] underwent excision of retrorectal tumours between 2002 and 2010 under the care of one surgeon. Seventeen (37.5%) had a malignant tumour. The commonest symptom was pain or discomfort. Features identified after MRI that suggested malignancy included heterogenous signal intensity (15/17 malignant lesions vs 5/39 benign lesions), an irregular infiltrative margin (14/17 malignant lesions vs 4/39 benign lesions) and enhancement (14/17 malignant lesions vs 2/39 benign lesions) (all P < 0.05). An abdominal approach was used in 27 (48%) patients, a perineal/trans-sacral approach in 20 (36%) and a composite abdomino-sacral approach in nine (16%). The perineal approach was used if the tumours were below the middle of S3 without sacral, pelvic side-wall or visceral involvement. The three most common types of tumour were schwannoma (n = 11), tail gut cyst (n = 13) and chordoma (n = 9). Over a median follow-up period of 46 (6-90) months there were two local recurrences among the malignant tumours (both resected) and two deaths (both sarcomas).

CONCLUSION

MR imaging, avoidance of routine preoperative biopsy and careful clinical evaluation result in a good outcome after surgical excision of retrorectal tumours.

Retrorectal cystic hamartoma (tailgut cyst): report of a case and review of literature

Retrorectal cystic hamartoma is a rare type of congenital cystic lesion usually diagnosed in middle-aged women. Although mostly asymptomatic, patients may present with symptoms resulting from local mass effect or with a complication. The most important complications of these cysts are infection with secondary fistulization and malignant degeneration. Because of such non-specific nature of symptoms and rare incidence, it is not unusual to have a delay in clinical diagnosis. MRI has evolved to be the investigation of choice for the evaluation of presacral tumors as it can provide excellent anatomic detail and soft tissue contrast. Role of preoperative biopsy is controversial especially with improvements in the imaging techniques. When diagnosed these lesions should be excised because of the risk of malignant transformation.

Posterior approach (Kraske procedure) for surgical treatment of presacral tumors

Presacral tumors are rare, but can comprise a great variety of histological types. Congenital tumors are the most common. Once the diagnosis is established, surgical resection is essential because of the potential for malignancy or infection. Previous biopsy is not necessary or may be even harmful. To decide the best surgical approach (abdominal, sacral or combined) an individual and multidisciplinary analysis must be carried out. We report three cases of cystic presacral masses in which a posterior approach (Kraske procedure) enabled complete resection, the only way to decrease local recurrence. All patients had a satisfactory recovery. A brief overview of retrorectal tumors is presented, focusing on classification, clinical presentation, diagnosis and surgical management.

Clinical Study and Review of Articles (Korean) about Retrorectal Developmental Cysts in Adults

Purpose

A retrorectal developmental cyst (tailgut cyst, epidermoid cyst, dermoid cyst, teratoma, and duplication) is very rare disease, and the symptoms are not characteristic so that sometimes this disease is still misdiagnosed as a supralevator abscess or a complex anal fistula. We would like to present a clinical approach to this disease.

Methods

We retrospectively examined the charts of 15 patients who were treated for retrorectal cysts from January 2001 to November 2009.

Results

All 15 patients were female. The average age was 41 years (range, 21 to 60 years). Fourteen patients (93.3%) were symptomatic, and the most common symptom was anal pain or discomfort. Nine patients (60%) had more than one previous operation (range, 1 to 9 times) for a supralevator abscess, an anal fistula, etc. In 12 patients (80%), the diagnosis could be made by using the medical history and physical examination. Thirteen cysts (80%) were excised completely through the posterior approach. The average diameter of the cysts was 4.8 cm (range, 2 to 10 cm). Pathologic diagnoses were 8 tailgut cysts (53.3%), 5 epidermoid cysts (33.3%) and 2 dermoid cysts (13.3%). The average follow-up period was 18.3 months (range, 1 to 64 months).

Conclusion

In our experience, high suspicion and physical examination are the most important diagnostic methods. If a female patient has a history of multiple perianal operations, a retrorectal bulging soft mass, a posterior anal dimple, and no conventional creamy foul odorous pus in drainage, the possibility of a retrorectal developmental cyst must be considered.

Local recurrence after intended curative excision of presacral lesions: causes and preventions

OBJECTIVE

This study was designed to explore causes for local recurrence of presacral lesions after intended curative surgery and discuss prevention strategies.

METHODS

Medical data of presacral lesions in our hospital from January 2001 to September 2009 were retrospectively studied, including preoperative examinations, intraoperative findings, and postoperative histopathologies.

RESULTS

Of 39 patients (29 women and 10 men) with presacral lesions, who ranged in age from 14 to 71 (mean, 39.56) years, 7 patients were diagnosed with recurrent presacral lesions on admission. Preoperative pelvic MRI, pelvic CT, and endorectal ultrasonography (ERUS) were performed in 23, 22, and 8 cases, respectively. MRI/CT showed that five cases had two coexisting lesions and three cases had lobulated or dumbbell shaped lesions, all of which were confirmed by intraoperative findings. ERUS suspected involvement of the rectal wall in three cases: adhesion to the rectal wall in two cases, and tumor invasion in the remaining case. During the operation, 26, 8, and 2 cases were resected by the transsacral, transabdominal, and combined abdominosacral approach, respectively. Four patients underwent simultaneous coccygectomy, and three patients received simultaneous resection of the sacrum and coccyx. Simultaneous partial resection of the invaded sigmoid colon or rectum was performed in two patients, respectively. By postoperative pathological examination, three cases were found to have ruptured cystic lesions, three had previous cyst rupture history, and five had infected lesions.

CONCLUSIONS

Presacral lesions are likely to be multiple, lobulated, infected, ruptured, and adhesive to the sacrococcyx and rectum, which contribute to the high local recurrence rate. Preoperative CT/MRI/ERUS and careful intraoperative exploration are required to direct surgical treatment and to reduce local recurrence. Optimal selection of surgical approach also is very important to reduce local recurrence. Presacral lesions attached to the sacrococcyx or rectum require simultaneous partial resection of the sacrococcyx or rectum to reduce local recurrence.

Retrorectal tumors

Tumors that arise in the retrorectal (presacral) space are uncommon lesions that present with nonspecific signs and symptoms, which lead to difficult diagnoses. For complete evaluation of the lesion, cross-sectional imaging is required to determine the extent of resection and the appropriate surgical approach. Surgical removal leads to favorable outcomes for patients with benign purely cystic retrorectal tumors. Preoperative tissue diagnosis with transperineal and transsacral biopsies of solid or heterogeneous cystic lesions, are essential to determine the necessity of neoadjuvant therapy, which may decrease local recurrence after surgery and avoid an unnecessary delay in systemic therapy.

Clinicopathological features of retrorectal tumors in adults: 9 years of experience in a single institution

Purpose

Primary tumors of the retrorectal space in adults are very rare. Most of them are benign masses, but malignant masses are reported on occasion. This study aimed to investigate the clinicopathological features of retrorectal tumors.

Methods

The medical records of fifteen patients who underwent surgical resection of a retrorectal tumor from March 2002 to April 2010 in our hospital were reviewed retrospectively.

Results

Out of 15 patients, thirteen were females and two males. About 1.7 patients were diagnosed with retrorectal tumor annually in our hospital. The incidence is one per 1,500 surgeries performed under general anesthesia. An anterior approach was performed in eight patients and a posterior approach with excision of the coccyx in five patients. Combined approach was performed in two patients. Four patients (three in abdominal approach and one in combined approach) underwent laparoscopic resection. The mean size of tumors was 6.2 ± 2.9 cm. Mature teratoma (four) and neurilemmoma (four) were the most common tumors. Except for one case of chondrosarcoma, fourteen tumors were confirmed to be of benign nature in histologic examination. Patients who underwent a transabdominal approach with laparoscopic surgery had no postoperative complication and had a tendency to experience earlier recovery than those with open surgery.

Conclusion

Surgical resection of a retrorectal tumor is recommended to relieve pressure symptoms and to confirm the diagnosis. A laparoscopic approach may offer excellent visualization of the deep structures in the retrorectal space, reduce surgical trauma, and be helpful for early postoperative recovery.

Retrorectal tumours: literature review and vilnius university hospital "santariskiu klinikos" experience of 14 cases

Objective

Retrorectal tumours are rare lesions in adults. The diagnosis of retrorectal lesion is often difficult and misdiagnosis is common. We present significant number of cases in view of scarce information available on this matter.

Methods

14 patients were treated at Vilnius university hospital "Santariskiu klinikos" Centre of abdominal surgery from 1997 to 2010. The case notes of patients who underwent surgery for a retrorectal tumour were reviewed retrospectively. Surgical histories, operations, histological tumour type, surgical time, weight of the specimen, blood loss, length of stay were analysed.

Results

13 patients underwent laparotomy, 1 patient had combined perineal approach and laparotomy. The most common types of the tumour were fibroma (3 cases), leiomyosarcoma (2 cases). 5 tumours (35,7%) were found to be malignant. 57% of the patients had undergone at least one operation prior to definitive treatment. 5 female patients were initially admitted under gynaecologists. Hospital stay varied from 14 days to 22 days (mean 16,2 days). A report of a representative case is presented.

Conclusions

Retrorectal lesions in female patients can mimic gynaecological pathology. Patients with this rare pathology are to be treated in a major tertiary hospital by surgeons, who are able to operate safely in the retrorectal space.

Castleman's disease of the mesorectum: report of a case

Castleman's disease is a benign lymphoid proliferative disorder, which most commonly presents as a solitary mass in the mediastinum, although extrathoracic sites have been reported in the neck, axilla, pelvis, mesentery, pancreas, and retroperitoneum. We report a case of asymptomatic, isolated Castleman's disease in the mesorectum, which is extremely rare. The patient was a 34-year-old woman who underwent investigations for vaginal spotting. A presacral mass was located on the left side of the rectum, 10 cm from the anal verge. Contrast-enhanced computed tomography showed a large, well-demarcated, strongly enhancing mass with internal radiating septa in the mesorectum. The mass was well circumscribed and isointense to muscle on T1-weighted magnetic resonance imaging, appearing as a slightly hyperintense mass on T2-weighted imaging. We performed laparoscopic mesorectal mass excision, and histological examination revealed features typical of the hyaline-vascular type of Castleman's disease. Thus, when a mesorectal mass is being investigated, Castleman's disease should be considered in the differential diagnosis.

Presacral tumors: diagnosis and management

Presacral tumors are uncommon lesions that can be difficult to diagnose because of their nonspecific presenting signs and symptoms. Cross-sectional imaging is essential in evaluating these lesions to determine the optimal surgical approach and the extent of resection. Surgery is the mainstay of treatment as it establishes the diagnosis and prevents the adverse consequences associated with malignant degeneration and secondary bacterial infection. The outcomes for patients with benign presacral tumors are favorable. Although there have been substantial improvements in the prognosis of patients with malignant presacral tumors, the development of newer adjuvant therapies are likely to further improve the oncologic outcomes of malignant presacral tumors such as chordomas and sarcomas.

Presacral epidermoid cyst in a male: a case report and literature review

Presacral cysts are an uncommon entity most often found incidentally in women. These tumors can arise from any of the 1 or more cell lines present in the presacral space during embryogenesis. We present a case of a 46-year-old male patient who was found to have a well-circumscribed presacral mass on computed tomography (CT) scan, which was obtained for his complaint of vague lower back pain. He underwent transabdominal excision, and pathology revealed a presacral epidermoid cyst filled with keratinaceous material. Presacral cysts are rare, especially in male patients. These tumors originate from an embryologic error during development. Because of the risk of infection and malignant transformation, they should be excised. Surgical options include a posterior approach, transabdominal approach, combined approach, or transrectal approach. The approach is dictated by the tumor size, location, presence of malignancy, and bony invasion.

Retrorectal tumors

Retrorectal or presacral tumors are rare and can be challenging to diagnose and treat. Because the retrorectal space contains multiple embryologic remnants derived from various tissues, the tumors that develop in this space are heterogeneous. Most lesions are benign, but malignant neoplasms are not uncommon. Lesions are classified as congenital, neurogenic, osseous, inflammatory, or miscellaneous. Although treatment depends on diagnosis and anatomic location, most retrorectal lesions will require surgical resection.

The presentation and management of presacral tumors

Objectives: Retrorectal masses are uncommon lesions. They remain a difficult diagnostic and therapeutic challenge despite the use of newer imaging modalities and improvement in preoperative care. Although useful for planning a resection, neither CT nor MRI can provide a definitive diagnosis. The objective was to remove the entire lesion as revealed by the radiological study to avoid any recurrence of disease and malignant degeneration, but with the least amount of consequential impairment. Methods: We present our experience with 9 (nine) presacral tumors during 10 year period 1998-2007. The files and charts of adults' patients who underwent treatment for presacral tumors were collected and retrospectively reviewed.Results: From January 1998 to December 2007, a total of 9 adult patients were evaluated for primary tumors originating in retrorectal space in Surgical Clinic of Oncology near University Hospital Center 'Mother Teresa'. Four patients were males and five were females. The diagnosis of these retrorectal tumors were, developmental tail gut cyst, teratoma, chordoma and chondrosarcoma. In six patients were achived good results during surgical treatment. Coccygeal resection in one case. In three cases we couldn't perform sarectomy. Conclusion: In conclusion, presacral tumors are uncommon. They can be congenital or acquired, benign or malignant, which forms the basis for a simple classification. Their treatment is always surgical. The good results were obtained in the benign lesions.

Retrorectal Tumors: The Choice of Surgical Approach Based on a New Classification

Because retrorectal-presacral tumors differ in histologic origin, symptoms, and prognosis, and often involve various neighboring structures, successful treatment of this heterogeneous group of tumors depends on the surgical approach chosen and the specialist surgeons involved. We investigated whether a new classification of retrorectal tumors based on findings from CT and MRI would simplify presurgical planning. The clinical records of a series of 34 patients who underwent surgery for retrorectal tumors from 1989 to 2003 were reviewed. Two radiologists, who were blind to the patients’ records, separately reviewed the preoperative CT and MRI findings and classified tumors according to whether they arose from the presacral area (Group 1), sacrum or spinal cord growing anteriorly (Group 2), or rectum growing posteriorly (Group 3). The preoperative CT and MRI findings for the retrorectal tumors yielded the information required to allow surgery to be properly planned (surgical approach and need to involve various specialist surgeons) in nearly all cases: 17 of the 18 patients (94.5%) with tumors arising from the retrorectal space, all 12 of those with tumors arising from the sacrum or spinal cord, and all four of those with rectal tumors. With the findings yielded by currently available CT and MRI techniques, retrorectal tumors can be anatomically and topographically classified preoperatively so as to allow surgery to be adequately planned in advance and thus optimize the surgical resection.

Transvaginal excision of a retrorectal tumor presenting as rectocele

Tumors occupying the retrorectal (presacral) space are uncommon and heterogeneous. It is estimated that an average of two patients with retrorectal tumors will be diagnosed per year in a standard metropolitan area. They are usually asymptomatic and diagnosed during routine physical examination incidentally. Our case was admitted with complaints of a swelling in her vagina, constipation, and difficulty in emptying her bowels. The diagnosis and treatment utilizing transvaginal approach in this case is discussed in comparison with the literature. Up to our knowledge, this is the first case presenting as rectocele and second case of retrorectal tumor surgically treated using transvaginal approach.

Algorithms for the surgical management of retrorectal tumours

BACKGROUND

Retrorectal tumours are uncommon and may present a surgical challenge. The aim of this study was to identify a surgical strategy based on information gained from the multidisciplinary management of retrorectal tumours.

METHODS

This was a retrospective review of 27 patients who had resection of retrorectal tumours between 1998 and 2006.

RESULTS

The tumours included ten cystic lesions, two mature teratomas, four chordomas, seven neurogenic tumours, two sarcomas, one angiomyxoma and one gastrointestinal stromal tumour. The diagnosis was suggested initially by non-specific clinical presentation and palpation of a retrorectal mass on examination (16 patients), pelvic imaging (six), obstructed labour (one), recurrent pilonidal sinus (one), recurrent perianal sepsis (one) and return of symptoms after resection (two). Magnetic resonance imaging (MRI) confirmed the diagnosis and enabled surgical planning. The operative approach was perineal (12 patients), abdominal (11) or combined (four). Factors that influenced the operative approach were tumour position, its neoplastic nature, involvement of the pelvic sidewall or pelvic viscera, and size. The retrorectal tumour recurred in three patients.

CONCLUSION

A successful multidisciplinary surgical strategy, based on preoperative localization by MRI, has been developed for the treatment of retrorectal tumours.

[Retrorectal tumors in adults. Experience in five cases]

The most frequent tumors that grow in the retrorectal space are embryological. Their management requires adequate knowledge of the characteristics of these lesions. We present five cases of retrorectal tumors.

Tératome bénin mature pré-sacré et formations kystiques vestigiales rétro-rectales chez l’adulte

Benign mature presacral teratomas or dermoid cysts occur rarely in the adult; the incidence is estimated at less than 1/40,000. They are considered to be retrorectal vestigial growths from embryonal rests; they are usually asymptomatic and discovered by chance. However, since they have a 20-30% risk of secondary infection and a 1-12.5% risk of malignant degeneration, they should undergo complete surgical resection. We present a case of presacral dermoid cyst in a young male and summarize the diagnostic and therapeutic management.

Pediatric presacral masses

Various types of masses may affect the presacral area in children. A presacral mass may be congenital or developmental or may arise from inflammation. The mass may have neural, vascular, lymphatic, or mesenchymal origins and may be primary (as in focal disease) or systemic (as in multifocal disease). Because the clinical manifestations of presacral masses are often nonspecific, imaging plays an important role in the detection and differentiation of these masses. Information obtained from imaging is also critical for management, especially for surgical planning. For these reasons, it is important that radiologists be familiar with the anatomy of the presacral region and with the imaging features of the various lesions that may occur in this region in children. For the accurate interpretation of findings, radiologists also must know the specific advantages and limitations of each of the imaging modalities used to evaluate this category of abnormalities.

Retrorectal tumors

Primary neoplasms of the retrorectal (presacral) space are very rare. These lesions may be congenital or acquired, benign or malignant. They often arise with subtle clinical symptoms, or they may be found incidentally during evaluation for other conditions. Preoperative imaging can provide useful information for operative planning; however, it does not eliminate the need for surgery. Approaches for resection include posterior only and combined abdominoperineal, depending on the characteristics of the lesion. Successful treatment of these enigmatic lesions requires extensive knowledge of pelvic anatomy and expertise in pelvic surgery.

Tumors of the retrorectal space

PURPOSE

Retrorectal tumors are a diverse group of masses derived from a variety of embryologic origins. Because of this, some confusion is associated with their diagnosis and management. Although rare, a basic understanding of the etiology, presentation, work-up, and treatment of retrorectal masses is essential.

METHODS

The incidence, classification, diagnosis, treatment, and prognosis of these masses are presented. A comprehensive review of the literature is included in our analysis.

RESULTS

Retrorectal lesions can be classified as congenital, inflammatory, neurogenic, osseous, or miscellaneous. Benign and malignant lesions behave similarly. The most common presentation is an asymptomatic mass discovered on routine rectal examination, but certain nonspecific symptoms can be elicited by careful history. Biopsy of these lesions should be avoided to prevent tumor seeding, fecal fistula, meningitis, and abscess formation. Complete surgical resection, usually after appropriate specialized imaging, remains the cornerstone of their treatment. Three approaches commonly used for resection are abdominal, transsacral, or a combined abdominosacral approach. Prognosis is directly related primarily to local control, which often is difficult to achieve for malignant lesions.

CONCLUSIONS

Retrorectal masses present a challenging surgical problem from diagnosis to treatment. A high index of suspicion and resultant early diagnosis, followed by thorough preoperative planning, is required for optimal management and outcome.

Retrorectal tumors: a diagnostic and therapeutic challenge

PURPOSE

Tumors occurring in the retrorectal space are heterogeneous and uncommon. The utility of newer imaging techniques has not been extensively described, and operative approach is variable. This study examined the diagnosis, treatment, and outcome of retrorectal tumors at a tertiary referral center.

METHODS

Patients with primary, extramucosal neoplasms occurring in the retrorectal space were identified using a prospectively maintained, procedural database of all adult colorectal surgical patients (1981-2003). Patients also were incorporated from the gynecologic oncology service. Exclusion criteria included inflammatory processes, locally advanced colorectal cancer, and metastatic malignancy. Medical records, radiology, and pathology reports were reviewed retrospectively.

RESULTS

Thirty-four patients with retrorectal tumors were treated. Malignant tumors comprised 21 percent. Older age, male gender, and pain were predictive of malignancy (P < 0.05). Sensitivity of proctoscopy was 53 percent; this increased to 100 percent with the use of transrectal ultrasound. Accuracy of magnetic resonance vs. computed tomographic imaging for specific histologic tumor type was 28 vs. 18 percent, respectively. Surgical approach was anterior (n = 14), posterior (n = 11), and combined abdominoperineal (n = 9). Eleven patients required en bloc proctectomy. Patients undergoing posterior resection had lower blood loss and required fewer transfusions (P < 0.05). All benign tumors were resected with normal histologic margins and none recurred (median follow-up, 22 months). All patients with malignancy had recurrence/recrudescence of their disease. For these patients, median disease-free and overall survivals were 38 and 61 months, respectively.

CONCLUSIONS

Retrorectal tumors remain a diagnostic and therapeutic challenge. Pain, male gender, and advanced age increase the likelihood of malignancy. Various imaging modalities are useful for planning resection but cannot establish a definitive diagnosis. Whereas benign retrorectal tumors can be completely resected, curative resection of malignant retrorectal tumors remains difficult.

Adenocarcinoma arising in a tailgut cyst with prominent meningothelial proliferation and thyroid tissue: case report and review of the literature

Tailgut cysts (retrorectal cystic hamartomas) are rare lesions occurring in the retrorectal/presacral space of young women, considered to be of developmental origin. In this study, we report the clinicopathological characteristics of an adenocarcinoma developing in an unusual tailgut cyst. A 47-year-old female presented with a 3-month history of an enlarging presacral mass, extending into the gluteal area. The patient underwent surgical resection. Microscopic examination revealed a mucinous adenocarcinoma with intestinal features arising in a tailgut cyst. In addition to the usual components previously described in this lesion (cuboidal, columnar, ciliated or squamous epithelial lining with scattered smooth muscle fibers in the wall), our case was unique in that it was associated with a meningothelial proliferation and benign thyroid tissue with oncocytic changes. These additional features bring into question the proposed hindgut origin of tailgut cysts.

Unusual retrorectal lesion

Retrorectal lesions are rare entities. We report the complete clinicopathological details of an unusual retrorectal lesion composed of low-grade endometrioid adenocarcinoma and propose that this is a malignant change in pluripotent cells arising within a long-standing retrorectal tailgut lesion. To the best of our knowledge, this is the first case report of this malignancy in a retrorectal tailgut cyst.

Resection of presacral ganglioneurofibroma by laparoscopy

BACKGROUND

Tumors of the retrorectal space are rare. They comprise a heterogeneous group of benign or malignant tumors that cause similar symptoms due to their location in presacral space. If possible, complete surgery excision is the therapy of choice mainly through a sacral, abdominal-sacral, or a pure abdominal or perineal axis.

CASE REPORT

A 15-year-old asymptomatic patient was diagnosed with a retrouterine tumor during her first gynecological examination. Magnetic resonance imaging of the pelvis showed a 10 x 8.5 x 7-cm encapsulated presacral tumor. Retrorectal ganglioneurofibroma was removed by laparoscopy with preservation of the sympathetic and parasympathetic nerves and the sacral roots of the ischiadic nerves. No sensory or motoric dysfunction of the legs, bladder, or rectum was observed postoperatively.

CONCLUSION

This is the first case report of a complete endoscopic removal of large presacral ganglioneurofibroma in an asymptomatic woman.

Presacral tumors: a practical classification and treatment of a unique and heterogeneous group of diseases

BACKGROUND

Presacral tumors are a rare and diverse group of diseases that originate from the different tissues that comprise the potential presacral space. Because of their relative rarity, confusion exists regarding their clinical presentation, natural history, and treatment. The aim of this study is to describe a single institution's experience with the management of presacral tumors and to suggest a practical method of classification.

METHODS

Records of all patients who underwent operation for presacral tumors from the years 1991 to 2001 were reviewed. Clinical, pathologic, treatment, and outcome variables were evaluated.

RESULTS

Forty-two patients were included in the study and were divided into 4 groups according to lesion pathology: benign congenital (n = 12), malignant congenital (n = 9), benign acquired (n = 9), and malignant acquired (n = 12). Symptoms were nonspecific, and 26% of the cases were completely asymptomatic. Diagnosis was made with rectal examination and confirmed with pelvic computerized tomographic scan. Surgical approach varied among the different groups, with the posterior approach used mainly for congenital tumors and the anterior approach for acquired. Complete surgical resection of the tumor was obtained in all cases of benign tumors and in 76% of malignant tumors. No postoperative mortality was seen, and complications occurred in 36% (15/42); most were reversible. None of the patients with benign tumors had recurrences, and all are alive at this time. The survival rate of patients with malignant tumors was significantly improved when complete resection was possible.

CONCLUSION

Classification of presacral tumors into congenital versus acquired and benign versus malignant is simple and efficient. Treatment is complete surgical resection, which can be performed safely with low morbidity and no mortality.

[Developmental cysts in the presacral space in adults]

Localization of primitive neoplasms the retrorectal or presacral space is rare in adults as most of these tumors are congenital. Developmental cysts are included within the group of retrorectal congenital cystic neoplasms and are slowly-progressive cystic neoplasms. Because of their localization, their manifestation is delayed, despite their congenital nature. Their form of presentation is varied and is caused by compression of the surrounding organs or infectious complications of the cyst.We describe two cases of presacral developmental cysts (one epidermoid cyst and one dermoid cyst) that presented in adulthood. Special attention is paid to the classification, and diagnostic and therapeutic problems of these tumors.

Tailgut cyst associated with a pilonidal sinus: an unusual case and a review

Tailgut cysts are rare congenital abnormalities in the retrocaecal/presacral region. Clinical diagnosis is difficult and delayed and they can present in childhood and adult life with a variety of clinical symptoms and complications. Differential diagnoses include, rectal duplication cysts, cystic teratoma, epidermal cyst, anal gland cyst and anal gland carcinoma. Magnetic resonance imaging has recently become the modality of choice to image these cysts. Although Tailgut cysts rarely undergo malignant transformation, early surgical resection is presently considered the treatment of choice. Here we report the case of a 34 year old gentleman with a Tailgut cyst associated with a Pilonidal sinus, and review of the literature. We believe that the high incidence of complications associated with operations in the presacral region should be weighed against the generally benign course of these lesions, especially with the quality of modern imaging technology.